CMS Pub. 100-04, ch. 29, § 330.1

A. Where Parties File Requests

To receive an ALJ hearing, a party to the QIC’s reconsideration must file a written request for

an ALJ hearing with the entity specified in the QIC’s reconsideration. The appellant must

also send a copy of the request for hearing to the other parties. Failure to do so will toll the

ALJ’s 90-day adjudication deadline until all parties to the QIC reconsideration receive notice

of the requested ALJ hearing. Also, if the request for hearing is timely filed with an entity

other than the entity specified in the QIC’s reconsideration, the ALJ’s deadline for deciding

the appeal begins on the date the entity specified in the QIC’s reconsideration (i.e., the

appropriate OMHA office) receives the request for hearing.

The QICs will specify the appropriate OMHA office as the filing location for ALJ hearing

requests.

B. Timely Filing Requirements

A party must file an ALJ request within 60 days of the date of their receipt of the QIC’s

decision. It is presumed that the appellant received the QIC’s decision within five days of the

date of the QIC’s decision, unless there is a reasonable showing by the appellant to the

contrary.

C. Content of the Request

The request for an ALJ hearing must be made in writing. The request must include all of

the following:

1. The name, address, and Medicare number of the beneficiary whose claim is

being appealed,

2. The name and address of the appellant, when the appellant is not the beneficiary,

3. The name and address of the designated representative, if any,

4. The document control number assigned to the appeal by the QIC, if any,

5. The dates of service,

6. The reasons the appellant disagrees with the QIC’s reconsideration or other

determination being appealed, and

7. A statement of any additional evidence to be submitted and the date it will be

submitted.

For the convenience of parties, OMHA provides forms that may be used to request a

Medicare ALJ hearing. It is not necessary, however, that this form be used to make a written

request.

• The request for hearing form “OMHA-100”:

https://www.hhs.gov/sites/default/files/OMHA-100.pdf

• In addition, the form OMHA‑100A is used as an attachment to form OMHA‑100

to identify multiple beneficiaries or enrollees associated with a single request for

an ALJ hearing or a review of dismissal. The direct link to form “OMHA-

100A”:

https://www.hhs.gov/sites/default/files/OMHA-100A-Multiple-Claim-

Attachment.pdf

• The link to OMHA’s webpage containing all forms:

https://www.hhs.gov/about/agencies/omha/filing-an-

appeal/forms/index.html

To request that OMHA make a decision without a hearing based only on the information that’s

in the appeal record, an appellant must submit the information required for an ALJ hearing

request and one of these:

• The “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form

(Form OMHA-104) available at https://www.hhs.gov/sites/default/files/OMHA-

104_Waiver_of_Right_to_an_ALJ_Hearing%200328.pdf; or

• A written request stating that you don’t wish to appear before an ALJ at a hearing

(including a hearing held by phone or video-teleconference), and explaining why

you decided to waive the hearing.

Even if a waiver of hearing is requested, a hearing may still be held by an ALJ if the other

parties in the case don’t also waive the ALJ hearing, or if the ALJ believes a hearing is

necessary to decide the case.